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Original Research Article
HOSPITAL BASED SCREENING FOR HIV (HUMAN IMMUNODEFICIENCY VIRUS) IN CHILDREN IN A
LOW RISK POPULATION - CROSS-SECTIONAL OBSERVATIONAL STUDY
Showkat Hussain Tali1, Shagufta Yousuf2, Kaisar Ahmad Kaul3
1Assistant
Professor, Department of Paediatrics, AIMSR, Bathinda, Punjab.
Professor, Department of Obstetrics & Gynaecology, AIMSR, Bathinda, Punjab.
3Professor, Department of Paediatrics, Government Medical College, Srinagar, Jammu and Kashmir.
2Assistant
ABSTRACT
BACKGROUND
Human Immunodeficiency Virus (HIV) infection is detected in a significant number of children globally. Since mass screening for
detection of HIV infection in children is not feasible in a low risk and resource limited state, it is worthwhile to find out these cases
among groups with high probability of the infection.
The aim of this study is to determine the probability of HIV infection, in a very low risk population, when a child is hospitalised
with at least one of the selected manifestations that is known to be significantly associated with HIV infection.
MATERIALS AND METHODS
Hospitalised children aged between 19 months and 12 years admitted with predefined clinical pointers were screened for HIV
infection by Micro-ELISA Kits. Positive micro-ELISA cases were subjected to Comb-Aid immune-blot test. Children positive for
Immunoblot test as well were considered HIV positive cases.
RESULTS
Hundred patients were enrolled in the study. Four patients were detected of having HIV infection. Clinical pointers in these cases
were fever (75%), hepatomegaly (75%), protein energy malnutrition (75%), cough (50%), recurrent bacterial infections (50%),
generalised dermatitis (50%), diarrhoea (50%) and oral thrush (50%). Clinical pointers with significant positive correlation were
recurrent bacterial infections, oral thrush and generalised dermatitis (p < 0.05).
CONCLUSION
Hospital-based screening using specific clinical pointers is a useful tool to detect HIV Sero-positive cases in a low risk population.
KEYWORDS
Human Immunodeficiency Virus, Children, Selective Screening, Clinical Pointer.
HOW TO CITE THIS ARTICLE: Tali SH, Yousuf S, Kaul KA. Hospital based screening for HIV (Human immunodeficiency virus) in
children in a low risk population - cross-sectional observational study. J. Evolution Med. Dent. Sci. 2017;6(7):550-553, DOI:
10.14260/Jemds/2017/117
BACKGROUND
An estimated 2.5 million children around the world are living
with Human Immunodeficiency Virus (HIV)/Acquired
Immunodeficiency Syndrome (AIDS) according to the 2010
report on the Global AIDS Epidemic released by Joint United
Nations Program on HIV/AIDS. India has an estimated
220,000 children infected by HIV/AIDS. Women and children
are increasingly becoming vulnerable to this disease. This
alarming trend is being observed closely as more HIV positive
mothers will unknowingly pass the virus on to their children.
Children under 15 years of age account for 4.4% of all
infections, while people aged 15 - 49 years account for 82.4%
of all infections.(1)
Early diagnosis of HIV infection in a child is not only
helpful in instituting prophylactic therapy, but also in
Financial or Other, Competing Interest: None.
Submission 14-12-2016, Peer Review 08-01-2017,
Acceptance 13-01-2017, Published 23-01-2017.
Corresponding Author:
Dr. Showkat Hussain Tali,
Assistant Professor,
Department of Paediatrics,
AIMSR, Bathinda, Punjab.
E-mail: [email protected]
DOI: 10.14260/jemds/2017/117
providing supportive care. However, undertaking diagnostic
workup to screen all children for HIV infection in the low risk
populations may not be that cost effective. When applied to
the individuals with high probability of HIV infection in a low
risk population, it is highly likely that cost effectiveness will
be improved reasonably.(2,3) Although, several studies have
been carried out in African countries(4-6) and many states of
India(2,3,7) to determine the likelihood of HIV infection with a
given clinical feature to the best of our knowledge. No such
study has been carried out in the Kashmir division of Jammu
and Kashmir state. As per NACO 2012 report, the state of
Jammu and Kashmir falls among the states with the lowest
HIV prevalence in India.(8) Hence, we conducted a prospective
study to determine the probability of HIV infection in a very
low risk population, when a child is hospitalised with at least
one of the selected manifestations that is known to be
significantly associated with HIV infection.
MATERIALS AND METHODS
This cross-sectional observational study was carried out at
GB Pant Children’s Hospital, Srinagar, which is a tertiary care
hospital for children in the state of Jammu and Kashmir,
India. The study was approved by Institutional Research
Board (IRB) and Ethical Committee of the College. All
children aged between 19 months and 12 years and admitted
with predefined clinical pointers (Table 1) were included in
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Original Research Article
this study. Written informed consent from parent/guardian
was taken prior to enrolment and screening. Pre-test
counselling was provided to the parent or guardian of all
patients regarding the nature of the study and implications
thereof.
Sl.
No.
Clinical Pointer
Sl. No.
1
2
3
4
5
6
7
8
9
Description
Documented Fever (Axillary
Temperature > 37.8 ̊C) ≥ 1 Month
2
Diarrhoea
≥ 2 loose Stools per Day ≥ 1 Month
3
Persistent Cough
Cough ≥ 1 Month
≥ Grade 3 PEM as Defined by
4
Malnutrition
Indian Academy of
Paediatrician’s Classification
Presence of Whitish Plaques in
Oral Cavity which could not be
5
Oral Thrush
easily Removed without Leaving
an Erythematous Base
Enlarged Lymph Nodes (> 1 cm
Generalised
in Axilla and >1.5 cm in Inguinal
6
Lymphadenopathy
Region) in ≥ 2 Non-Contagious
Sites for > 2 Months
Liver below Costal Margin
7
Hepatomegaly
> 4 - 7 cm (As per age)
as Detected Clinically
Generalised
Including Eczema and
8
Dermatitis
Maculopapular Dermatitis
Chronic
Swelling of at least 1
9
Parotid
Parotid Gland for a Minimum
Swelling
Period of 3 Months
Occurrence of > 2 Episodes of
Recurrent
Serious Bacterial Infections
10
Bacterial
such as Pyogenic Meningitis
Infection
or Pneumonia in Past 2 Years
Miliary Tuberculosis or
Disseminated
CNS Tuberculosis or Pulmonary
11
Tuberculosis
Tuberculosis in Conjunction
with Abdominal Tuberculosis
Diagnosed on the Basis
of Clinical Features,
Pneumocystis
12
Arterial Blood Gas Analysis,
Carinii pneumoniae
Chest Radiography and
Microbiological Studies
Table 1. Definition of Predetermined Clinical Risk Factors
1
RESULTS
A total of 100 patients were enrolled in the study. Four were
sero-positive for HIV infection. Baseline characteristics of the
study population are depicted in Table 2.
Fever
After recruitment, details of demographic data, history
and physical examination findings were recorded in a
predesigned proforma. Five millilitres (5 mL) of venous blood
were collected and were sent to laboratory for HIV screening
by Micro-ELISA Kits. Micro-ELISA positive cases were subject
to Comb-Aid immunoblot testing in sequence. When both the
tests were positive, HIV was confirmed as per National AIDS
Control Organisation (NACO) guidelines. CD4 count was done
in every patient who was confirmed HIV positive. As a
secondary end point of the study, the parents of children
(children who eventually were HIV positive) were screened
for HIV infection after offering pre-test counselling.
Statistical Analysis
The data was analysed using the SPSS software programme
version 18. Chi-square test was used with Yates correction.
Relative Risk and Odds Ratio were determined wherever
applicable.
1
2
Age (Months)
No. of Patients
19 - 32
6 (6%)
33 - 46
4 (4%)
47 - 60
9 (9%)
61 - 74
5 (5%)
75 - 88
7 (7%)
89 - 102
10 (10%)
103 - 116
17 (17%)
117 - 130
14 (14%)
131 - 144
28 (28%)
Total
100 (100%)
Gender
Male
58 (58%)
Female
42 (42%)
Total
100 (100%)
Table 2. Age and Gender of
the Study Population (n = 100)
No. of subjects (total and sero-positive) with a predefined
clinical pointer are in shown in Table 3. Statistical analysis is
shown in Table 4. Correlation of no. of risk factors with seropositivity is shown in Table 5. Demographic and other
characteristics of HIV sero-positive cases are in Table 6.
Sl.
No.
Clinical
Pointers
1
Total No. of
Subjects
(Percentage);
N=100
No. of HIV Seropositive
Cases
(Percentage);
N=4
3 (75%)
Fever (> 1 month)
48 (48%)
Diarrhoea
2
12 (12%)
2 (50%)
(> 1 month)
3 Cough (> 1 month)
27 (27%)
2 (50%)
Malnutrition
4
33 (33%)
3 (75%)
(Grade III or more)
5
Oral Thrush
4 (4%)
2 (50%)
Generalised
6
8 (8%)
2 (50%)
Lymphadenopathy
7
Hepatomegaly
46 (46%)
3 (75%)
Generalised
8
3 (3%)
2 (50%)
Dermatitis
Chronic Parotid
9
0 (0%)
0 (0%)
Swelling
Recurrent Bacterial
10
8 (8%)
0 (0%)
Infection
Disseminated
11
18 (18%)
0 (0%)
Tuberculosis
Pneumocystis
12
0 (0%)
0 (0%)
Carinii Pneumoniae
Table 3. Total No. of Subjects with a Specific
Clinical Pointer and No. of HIV Sero-Positive
Subjects having that Clinical Pointer
DISCUSSION
In our study, there was a statistically significant correlation
between presence of recurrent bacterial infection, oral thrush
and generalised dermatitis and the prediction of HIV
infection sero-positivity (p < 0.05). Although fever, severe
malnutrition and hepatomegaly were the most common
findings in HIV positive patients, they did not predict HIV
sero-positivity.
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Original Research Article
Clinical
Pointers
Fever (> 1 Month) (n = 27
Cough (> 1 Month) (n = 27)
Severe Malnutrition
Recurrent Bacterial Infection (n = 9)
Generalised Dermatitis (n = 3)
Hepatomegaly (n = 46)
Chronic Diarrhoea (n = 12)
Oral Thrush
HIV SeroHIV Serop
X2
Positive
Negative
Valve
3 (6.25%)
45 (93.75%)
0.35
> 0.05
2 (7.4%)
25 (92.59%)
0.233
> 0.05
3 (9.09%)
30 (90.90%)
1.64
> 0.05
2 (25%)
6 (75%)
5.38
< 0.05π
2 (66.66%)
1 (33.33%)
17.04 < 0.05π
3 (6.97%)
43 (93.4%)
0.456
> 0.05
2 (16.66%)
10 (83.33%)
2.56
> 0.05
2 (50%)
2 (50%)
12.17 < 0.05π
Table 4. Statistical Assessment
Odds
Ratio
4.05
1.35
3.45
1.04
1.010
3.81
1.16
1.02
Specificity
Sensitivity
53
74
69
94
99
55
89
98
75
50
75
50
50
75
50
50
π = P value Statistically Significant
The strength of our study is that it has shown the
feasibility of applying clinical pointer based screening tool in
a very low risk population for HIV infection detection.
However, the results of our study would not be applicable to
screening of asymptomatic children as our target population
were symptomatic in hospitalised children. Furthermore,
children aged 18 months and younger were not enrolled as
diagnosing HIV infection in them would need performance of
HIV, DNA, PCR which was not possible because of economical
constraints.
Common clinical manifestations in HIV positive patients
were fever (75%), severe malnutrition (75%), hepatomegaly
(75%), cough for more than one month (50%), chronic
diarrhoea (50%), recurrent bacterial infection (50%), oral
thrush (50%) generalised dermatitis (50%). These findings
are consistent with other published studies.[9,10] Although,
generalised lymphadenopathy is a common presenting risk
factor for HIV in hospitalised children,[2,7] our observation did
not reveal any such finding. Also, no case of disseminated
tuberculosis was reported in our study, which is also a
common clinical pointer[11] for detecting HIV sero-conversion
in this population. This may be due to the fact that less
number of subjects was enrolled in our study.
In this study, generalised dermatitis, oral thrush and
recurrent bacterial infections were significant predictors for
detection of HIV positivity rate (p < 0.05), which is consistent
with other studies.[12,13,3] Patients with single clinical risk
factor had a sero-positivity rate of 3.7%, patients with 5
clinical risk factors had sero-positivity rate of 50% and those
with 6 or 7 such factors predicted a rate of 100%. This study
shows that as the number of predefined clinical risk factors
increases, the probability of sero-conversion to HIV also
increases. This finding correlates well with the findings of
other studies.(3)
Case
No.
1
2Ω
3Ω
4
Mother
Sero-Positive
Yes
?¥
?¥
?€
No. of
Risk
Factors
Present
1
2
3
4
5
6
7
HIV
Total No. of
HIV
Positive
Subjects with
Negative
Cases (n = 4)/
the Clinical
Cases
Percent
Pointer
(n = 96)
of Total
(n = 100)
1 (3.7%)
27
(28)
0 (0%)
41
(41)
0 (0%)
22
(22)
0 (0%)
5
(05)
1 (50%)
1
(02)
1 (100%)
0
(01)
1 (100%)
0
(01)
Table 5. Risk Factor Correlation
(HIV Positive Vs HIV Negative)
In our study, all HIV sero-positive cases were from rural
areas. This may be related to low education level and lack of
healthcare awareness in such populations.
At the time of admission in the hospital, there was no
family history of HIV infection or AIDS in any of the studied
100 patients including HIV positive cases. On contact tracing,
first patient had both mother and father positive for HIV
infection. The other two patients (siblings) provided history
of prolonged maternal illness (pulmonary tuberculosis) and
death, although no HIV testing was performed on her. The
fourth patient’s mother had died of recurrent pneumonias,
but was never screened for HIV infection. None of the affected
patients had received any blood transfusion. There was no
history of sexual abuse or repeated syringe use in any of the
affected patients (Table 5). So most probably the
transmission of the disease was vertical, which is consistent
with other studies.(14)
Father
Blood Transfusion/Sexual
Male (M)/
Rural (R)/
Sero-Positive Abuse/Exposure to Injections Female (F)
Urban (U)
Yes
No
F
R
No
No
M
R
No
No
M
R
Yes
No
F
R
Table 6. Demographic and other Characteristics of HIV Sero-Positive Cases
CD4 Count/
mm3
1340
560
720
350
¥ = Mother had died of pulmonary tuberculosis, but never tested for HIV. € = Mother had died of recurrent chest infections, but
never tested for HIV. Ω = Siblings.
CONCLUSION
Our study suggests that the hospital-based, clinically-directed
screening has a practical role in diagnosis of HIV infection in a
resource limited settings even in low prevalence population.
Moreover, contact tracing may be an effective tool in
searching for hidden HIV infected cases.
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REFERENCES
[1]
Pandey A, Sahu D, Bakkali T, et al. Estimate of HIV
prevalence and number of people living with HIV in
India 2008-2009. BMJ Open 2012;2(5):e000926.
[2]
Ojukwu JU, Ogbu CN. HIV infection in hospitalized
children with endemic diseases in Abakaliki, Nigeria:
the role of clinically directed selective screening in
diagnosis. AIDS Care 2007;19(3):330-6.
[3]
Bavdekar SB, Agarwal R. Clinically directed selective
screening for HIV infection in hospitalized children.
Indian Pediatr 2005;42(12):1191-7.
[4]
Esamai F, Buku GM. HIV sero-positivity in children
admitted with diarrhoea at Eldoret district hospital,
Kenya. E Afr Med J 1994;71(10):631-4.
[5]
Lepage P, Van de Perre P, Nsengumuremye F, et al.
Bacteremia as predictor of HIV infection in African
children. Acta Paediatr Scand 1989;78(5):763-6.
[6]
Pallangyo K, Hakanson A, Lema L, et al. High HIV
seroprevalence
and
increased
HIV-associated
mortality among hospitalized patients with deep
bacterial infections in Dar es Salaam, Tanzania. AIDS
1992;6(9):971-6.
[7]
Emodi IJ, Okafor GO. Clinical manifestations of HIV
infection in children at Enugu, Nigeria. J Trop Pediatr
1998;44(2):73-6.
Original Research Article
[8]
[9]
[10]
[11]
[12]
[13]
[14]
NACO (2012) 'HIV Sentinel Surveillance 2010-2011, a
Technical Brief'. Accessed on June 2014.
Merchant RH, Oswal JS, Bhagwat RV, et al. Clinical
profile
of
HIV
infection.
Indian
Pediatr
2001;38(3):239-46.
Pol RR, Shepur TA, Ratageri VH. Clinico-laboratory
profile of pediatric HIV in Karnataka. Indian J Pediatr
2007;74(12):1071-5.
Merchant RH, Shroff RC. HIV sero-prevalence in
disseminated tuberculosis and chronic diarrhoea.
Indian Pediatr 1998;35(9):883-7.
Lodha R, Singhal T, Jain Y, et al. Paediatric HIV
infection in a tertiary care centre in north India: early
impressions. Indian Pediatr 2000;37(9):982-6.
Madhivanan P, Mothi SN, Kumarasamy N, et al. Clinical
manifestations of HIV infected children. Indian J
Pediatr 2003;70(8):615-20.
Coutsoudis A, Kwaan L, Thomson M. Prevention of
vertical transmission of HIV-1 in resource-limited
settings. Expert Review of Anti-Infective Therapy
2010;8(10):1163–75.
J. Evolution Med. Dent. Sci./eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 6/ Issue 07/ Jan. 23, 2017
Page 553